Canada James Baawuoh Kristin Bunney Kaitlynn Coombs Jennifer

Canada James Baawuoh, Kristin Bunney, Kaitlynn Coombs, Jennifer Elizalde, Veronica Garza, Natalie Walters

Nature and Structure • The Canadian health care system is referred to as national health insurance (NHI), or a single payer system • Canada’s national health insurance is also referred to as “Medicare” • The Canadian health care system is considered decentralized because Canada is made up of 10 different provinces, each possessing some autonomy and offering its own unique health care systems • The amount of federal funding that each province receives varies depending on its population size • The federal and territorial governments play a supervisory role over each province • The federal government controls costs and spending of hospitals

Nature and Structure, Cont’d • Private health insurance is optional and used in conjunction with the public health insurance • Private health insurance only covers health care services that are not defined by public health insurance, such as: • • • Dental care Prescription drugs Prescription eyeglasses Ambulance services Private hospital rooms • Canadian citizens have the ability to choose their own doctor, as well as place of care (i. e. , private doctor’s offices, hospitals, or urgent care centers)

History of Canada’s Health Care System • Canada's Constitution defined the powers of the federal and the provincial and territorial governments under the Constitution Act of 1867, which stated: • Provinces were given the responsibility of creating, maintaining and managing hospitals, asylums, charities, and charitable institutions • The federal government was in charge of managing marine hospitals and quarantine • Federal health responsibilities were covered by the federal department of Agriculture from 1867 until 1919, when the department of Health was created • The majority of health care in Canada was privately provided and funded before World War II (1939 -1945)

History, Cont’d • In 1947, the provincial government of Saskatchewan initiated the first province-wide, universal hospital care plan in Canada • By 1950, British Columbia and Alberta had also established province-wide, universal hospital care plans that were similar to the hospital care plan in Saskatchewan • In 1962, Saskatchewan introduced the first public medical insurance plan, which provided doctors' services to all residents of Saskatchewan • Doctors in Canada did not support this plan and reacted by going on strike, which ended after just 3 weeks

Canadian Health Care Legislation Leading Up to the Canada Health Act of 1984 • The Hospital Insurance and Diagnostic Services Act of 1957 • Offered to reimburse one-half of provincial and territorial costs for specific hospital and diagnostic services • Provided for publicly funded universal coverage for specific services under established terms and conditions • In 1971, all provinces and territories had agreed to provide publicly funded inpatient hospital and diagnostic services • The Medical Care Act of 1966 • Offered to reimburse one-half of provincial and territorial costs for medical services provided by private practice doctors • Within six years, all provinces and territories had universal physician services insurance plans

The Canada Health Act of 1984 • The Canada Health Act is Canada’s federal legislation for public health insurance, which replaced all former federal hospital and medical insurance acts • By consolidating the criteria of former acts, the Canada Health Act established five principles, which includes: 1. 2. 3. 4. 5. Public Administration Comprehensiveness Universality Accessibility Portability • This act also added provisions that prohibited extra billing and user fees for insured services, and was put in place to ensure that all Canadian citizens receive necessary and adequate health care

Principles of the Canada Health Act of 1984 1. Public Administration • Plans must be administered and operated on a non-profit basis by a public authority accountable to the provincial or territorial government 2. Comprehensiveness • Plans must insure all medically necessary services provided by hospitals, medical practitioners, and dentists working within a hospital setting 3. Universality • Plans must entitle all insured persons to health insurance coverage on uniform terms and conditions 4. Accessibility • Plans must provide all insured persons reasonable access to medically necessary hospital and physician services without financial or other barriers 5. Portability • Plans must cover all insured persons when they move to another province or territory within Canada and when they travel abroad

Accessibility • To receive universal health care coverage, Canadian residents must apply for a provincial health card. The card is used by providers to access the patient’s medical history when seeking treatment. • The Canada Health Act requires all residents to be accepted under public health care coverage. • The waiting period for new immigrants to receive coverage cannot exceed three months. • Once a provincial health card is issued, residents typically have few forms or low individual service fees under public health care providers.

Accessibility • Canadians visit doctors an average of 6 times per year (Americans visit 4 times per year). • There minimal fees for medical care. • Canadians are less likely to avoid seeking medical care due to financial reasons. • Canadians are less likely to become bankrupt due to medical treatment costs. • Finger reattachment costs $12, 000 -60, 000 in US Same procedure in Canada is free.

Accessibility • The population is heavily concentrated along southern border. As such, medical care personnel and facilities are located more densely along southern border. • Since access to medical care is concentrated in heavily populated rural areas, northern regions and poorer areas have less access to health care. • For every 1, 000 Canadians there is 1 primary care doctor. • Each province has some independence in offering a different health care system. • Residents can move to other provinces without losing health coverage.

Accessibility • Canadians have a long wait time for technologically advanced care, but is rarely life threatening. • Private clinics offer reduced wait times compared to the public health care system but it requires private insurance or higher out of pocket payments. • Canadians have less coronary bypass surgery: • Represents an overuse in US rather than underuse in Canada. • After heart attacks, Americans are 5 times more likely to receive a coronary angiography and 8 times more likely to receive coronary bypass surgery. After 1 year survival rates are equal for both countries.

Funding • Funded (70%) public sector and (30 %) private sector • Financed via taxation • Government supports the NHI program by fiscal transfers (cash contributions and taxes). However, it will only do so if provinces and territories comply with 5 criterion in Canada Health Act. • Federal taxes: foundation of govt. transfer payments to provinces • Provincial taxes: income, payroll, and sales taxes

Global Budgets • Most common source of funding for healthcare • It is a fixed amount distributed to a hospital or provider to cover operational expenses for a period of time, usually one year. • Has spending cap or limit to control health costs • It funds: Most hospitals, long-term care facilities, publicly funded rehabilitation facilities, and mental as well as public health programs.

Cons to Global Budgets • Providers restrict access to services or limits the number of admissions to a facility • They provide little incentive for innovation to improve efficiency of care • Do not provide opportunities for increased revenue, healthcare providers have no incentive to shorten • Length of stay or to discharge patients to lower cost healthcare settings • Do not provide coordination across service providers in acute and post acute settings. • It creates a system of inefficiencies and reduced quality of care.

Spending • In 2013 Canadians spent $211 billion dollars on Healthcare or about $5, 988 per patient • 30% spent on hospitals (expected to increase by 2. 6%) • 16 % spent on drugs (expected to increase by 2. 4%) • 15 % spent on physicians (expected to increase by 3. 6 %) • 70% of healthcare spending is taken care of by provincial or territorial government • Provinces spend about 40% of their budget on healthcare

Who spends the most?

Canada vs. United States (Spending)

Canada vs. United States (Spending) • The data shows government health-care spending per capita in the United States and Canada. The United States spends more

Role of Healthcare Providers • Physicians act as “gatekeepers” to ensure health services are used appropriately • Health care providers are mostly private but publically funded • Physicians mainly in private practice and compensated on a fee for service basis • Doctor decides on the means of treatment rather than the insurance company • Specialists are usually only used via referral from physician • More emphasis on NP rather than PA

Physicians • Completion of 4 year bachelors degree preferably in sciences such as chemistry or biology • After bachelors (2 year min) for family practice or (4 year min) for specialty • Followed by 3 year residency • Physician must be licensed by provincial or territorial licensing authority • Salaries vary from province to province • Seen as gatekeepers

Average Salary and Increase in Number of Physicians by Province

Nurses • Registered Practical Nurse: 2 or 3 year diploma. Tends to deal with patients with less severe complications or illnesses • Registered Nurse: 4 year bachelors degree. Deals with patients with all sort of issues from minor to complex • Nurses are awarded licenses by the jurisdiction in the province or territory in which they wish to practice in • Salaries or wages vary from province to province based on demand seniority as well as education • Play major role in delivery of health care

Nurse Practitioner Is an RN with more experience and education Requires at least a Masters degree in Nursing Can prescribe some medication, read diagnostic reports etc. There about 3, 000 NPS across Canada (mainly in Ontario though) • This career is highly promoted and valued in Canada • Provide direct care to patient and emphasize health promotion • NP’s play major role in accessibility of health care to reduce waiting list times. • •

Canada vs. the United States • The nature of the U. S health care system is “entrepreneurial” • In the U. S. there is a decline in longstanding doctor-patient relationships due to insurance programs constantly changing their lists of contracted doctors (U. S. citizens have limited ability to choose their own doctors) • There is more emphasis on Physician Assistant role in the U. S. • Nurse Anesthetists are used in the U. S. (Canada has just began starting programs for Nurse Anesthetists) • The U. S. has greater a number of advanced practice nursing roles • The role of nurses is more broad in the U. S.

Affordability • Before inflation, the cost of public health care insurance went up by 53. 3% over the last decade. • The bills are smaller for the average unattached individual ($3, 780), The average one-parent-one-child family ($3, 905), And the average one-parent two-child family ($3, 387). • In 2013, a typical Canadian family of four can expect to pay $11, 320 for public health care insurance and for the average family of two parents with one child that bill will be $10, 989. Average family of two adults (without children) the bill comes to $11, 381.

Affordability • In Canada, there are no necessary co-pays or deductibles; everyone is essentially covered through their taxes. • An increasing majority supports their Canadian health care system, which costs half as much, person, as in the United States. • Canada's health care system is the developed world's most expensive universal-access health care program after adjusting for the age of the population (older people require more care). • While Canadians are getting a raw deal for their health care dollars, patients in Belgium, France, Germany, Japan, Luxembourg, the Netherlands, and Switzerland receive universal access to health care without lenghty queues.

Effectiveness • • In 2009, heart attack was the leading cause of death from circulatory diseases, at 32 deaths per 100, 000 Canadians. Lung cancer was the leading cause of death from cancer, at 44 deaths per 100, 000. Mortality for heart attack, stroke, and prostate cancer decreased between 2000 and 2009. Heart attack mortality decreased from 56 deaths per 100, 000 Canadians in 2000 to 32 in 2009. Stroke mortality fell from 42 to 28 deaths per 100, 000 Canadians. Prostate cancer mortality decreased from 27 to 20 deaths per 100, 000 men. Breast cancer decreased, from 25 to 20 deaths per 100, 000 women.

Effectiveness The Mortality rate for heart attack, stroke, colorectal and lung cancers was higher for men than women in 2009, with the exception for gender-specific cancers, men were more likely to die from these diseases than women.

Effectiveness In 2009, mortality for heart attack, stroke and all cancers (excluding gender-specific cancers) ranged from 205 deaths per 100, 000 people in British Columbia to 410 deaths per 100, 000 in Nunavut. Ontario, Saskatchewan, Alberta and British Columbia had lower mortality for these illnesses than the national average.

Effectiveness • Canada’s infant mortality rate is lower now than it was in previous decades. Canada’s infant mortality dropped from grade B in the 1960’s, 1970’s, and 1980’s, to grade C in the 1990’s and 2000’s • Canada’s infant mortality rate fell significantly between 1960 and 1980—from 27 deaths per 1, 000 live births to 10 deaths • In 2007, Canada’s infant mortality rate, or the number of deaths of children less than one year of age, per 1, 000 live births was 5. 1. This was significantly higher than the rate in almost all of its peer countries. Canada earns a “C” on this indicator. The only comparable country with a worse record on infant mortality is the U. S. , with 6. 5 infant deaths per 1, 000 live births.

Effectiveness • Males and females aged 20 to 34 had the highest rate of being without a regular medical doctor. For males, the rate decreased with age starting at 20. The percentage of females without a regular medical doctor decreased between the ages 20 and 54, and again after age 64 (Chart 2). • In 2013, males were significantly more likely than females to report being without a regular doctor in all age groups from 12 to 64 years of age (Chart 2). There was no significant difference between males and females in the 65 or older age group.

Effectiveness • Canada ranked 5 th out of 6 countries for Health prevention o Pap smears, mammograms, flu shots, patient reminders for preventive care • o o o Canada ranked 1 st out of 6 countries with respect to primary care Review of medications Explanation of side effects Provision of advice on diet and exercise Asking if emotional issues are affecting health Patients adherent to recommendations

Effectiveness Despite universal health insurance, barriers to access to primary health care exist in Canada. These barriers include: • Being poor or poorly educated impairs overall access to family physician services and preventive care • Challenge of blended models that favor large roster sizes – concern some physicians screening potential new patients and choosing those that are healthy • Risk adjustment based on age and sex in Canada but case mix and morbidity not

Effectiveness Shortage of family physicians • In 2006, Canada ranked behind 6 other countries* in terms of: • Use of information technology and clinical information systems • E. g. , use of EMRs, electronic ordering of tests and prescribing of medication, electronic access to test results and hospital records • Coordination of care • E. g. , Timely receipt of full discharge reports from hospital, receipt of information about results from a referral *Australia, Germany, the United States, The Netherlands, New Zealand, and the United Kingdom

References • Bernard, E. (1992). The Politics of Canada's Health Care System. New Politics, 3 (4). • Chai, C. (2013, October 29). By the numbers: How much did Canada spend on health care in 2013? Retrieved October 1, 2014, from http: //globalnews. ca/news/932105/bythe-numbers-how-much-did-canada-spend-on-health-care-in-2013/ • Esmail, N. (2013, August 9). 'Free' Health Care in Canada Costs More Than It's Worth. Retrieved October 15, 2014, http: //www. huffingtonpost. ca/nadeem-esmail/canadafree-health-care_b_3733080. html • Irvine, B. , Ferguson, S. , & Cackett, B. (2013, January 1). Healthcare Systems: Canada. Retrieved October 1, 2014, from http: //www. civitas. org. uk/nhs/download/canada. pdf • Marchildon, G. (2013). Canada Health System Review. Health Systems in Transition, 15 (1), 19 -54. • Mc. Donald, J. (2014, February 1). Becoming a Physician. Retrieved October 1, 2014, from http: //counselling. athabascau. ca/physician. php

References, Cont’d • Nader, R. (2013, November 22). 21 Ways the Canadian Health Care System is Better than Obamacare. Retrieved October 18, 2014, from http: //www. counterpunch. org/2013/11/22/21 -ways-the-canadian-health-caresystem-is-better-than-obamacare/ • Sutherland, J. (2013). Current Funding. Retrieved October 1, 2014, from http: //healthcarefunding. ca/key-issues/current-funding/ • Thomson, S. , Osborn, R. , Squires, D. , & Jun, M. (Eds. ). (2013, November 1). International Profiles of Health Care Systems, 2013. Retrieved October 1, 2014. • Weitz, Rose. (2013). The Sociology of Health, Illness, & Heath Care (6 th ed. ) (pp. 212 -217). Boston, MA: Wadsworth • Wilson, L. (n. d. ). The Effectiveness and Efficiency of Canada's Primary Health Care System. Retrieved October 1, 2014.

References, Cont’d • Access to a Regular Medical Doctor, 2013. (2013). Retrieved October 1, 2014, from http: //www. statcan. gc. ca/pub/82 -625 x/2014001/article/14013 -eng. htm • Canada's Health Care System. (2012, October 1). Retrieved October 1, 2014, from http: //www. hc-sc. gc. ca/hcs-sss/pubs/system-regime/2011 -hcssss/index-eng. php • Canada's Health Care System (Medicare). (2010, December 1). Retrieved October 1, 2014, from http: //www. hc-sc. gc. ca/hcs-sss/medi-assur/indexeng. php • Canadian Health Care. 2004. Web. 23 October 2014. http: //www. canadianhealthcare. org/page 7. html

References, Cont’d • Health - Mortality From Leading Diseases. (2014). Retrieved October 1, 2014, from http: //www 4. hrsdc. gc. ca/. 3 nd. 3 c. 1 t. 4 r@-eng. jsp? iid=5 • Infant Mortality. (2012, February 1). Retrieved October 1, 2014, from http: //www. conferenceboard. ca/hcp/details/health/infant-mortalityrate. aspx • Life Expectancy. (2012, February 1). Retrieved October 1, 2014, from http: //www. conferenceboard. ca/hcp/details/health/lifeexpectancy. aspx • Making Medicare: The History Of Health Care In Canada, 1914 -2007. (2010, April 1). Retrieved October 1, 2014, from http: //www. historymuseum. ca/cmc/exhibitions/hist/medicare/medic 0 1 e. shtml • Sicko. (2007). Retrieved from http: //www. filmsforaction. org/watch/sicko/